STOP FALLS OR RISK PAYMENT DENIALS TABLES

Figure 1

FMEA Project Matrix (Part 1)

Process Step	Potential Failure Mode	Potential Effect	Severity of Effect	Probability of Failure	Detectability of Failure	Criticality Score
Conduct initial assessment using Morse Fall Risk Assessment tool	Patient’s fall history not available at time of initial assessment	Incomplete assessment	5	2	1	10
	Patient’s report of his/her fall history is not reliable	Inaccurate Morse score	5	2	1	10
	Nurse does not accurately calculate fall risk using Morse Assessment tool	Inaccurate Morse score	4	1	4	16
Record total score on the patient’s interdisciplinary care plan	Score not recorded	Caregivers not made aware of patient’s fall risk; proper fall prevention precautions not instituted	5	2	1	10
Implement high-risk fall prevention plan of care if Morse Fall Risk score is 50 or higher or nurse judges patient to be at higher-than-normal risk of fall	Not enough equipment (chairs, bed alarms, signage)	Delay in implementing fall precautions	5	1	1	5
	All shifts and disciplines do not implement interventions consistently	Increased risk of patient fall	5	3	5	75
	Fall prevention plan not implemented as required by policy/procedure	Increased risk of patient fall	5	1	2	10
Communicate patient’s fall risk to other disciplines	Inadequate communication among disciplines	Other disciplines not made aware of patient’s fall risk; proper fall prevention precautions not used	5	5	3	75
Monitor high-risk patient according to fall prevention policy/procedure and reassess fall risk as indicated	Patient not monitored as required by policy/procedure	Increased risk of patient fall	5	2	4	40
	Fall risk reassessments not documented in patient record	All caregivers/disciplines not made aware of patient’s current fall risk; increased risk of patient fall	5	2	2	20
Educate patient and family	Patient has impairment that prevents education	Patient unable to cooperate causing increased risk of fall	3	5	1	15
	Family does not adhere to recommendations	Increased risk of patient fall	3	2	4	24
	Education not done	Increased risk of patient fall	3	2	4	24

Severity Rating Scale 1 = No effect 2 = Minimal effect 3 = Moderate, short-term effect 4 = Significant, long-term effect 5 = Catastrophic

Probability Rating Scale 1 = It is highly unlikely/it’s never happened before 2 = Low/relatively few failures 3 = Moderate/occasional failures 4 = High/repeated failures 5 = Very high/failure almost inevitable

Detectability Rating Scale 1 = Almost certain to be detected and corrected 2 = High likelihood of detection and correction 3 = Moderate likelihood of detection and correction 4 = Low likelihood of detection and correction 5 = Remote likelihood of detection and correction

Figure 2

FMEA Project Matrix (Part 2)

Critical Failure	Root Causes	Actions Intended to Eliminate/Reduce Failure or Mitigate Effects
All shifts and disciplines do not implement interventions consistently	Lack of training for nonnursing caregivers and transport staff	· Fall prevention training for all nonnursing caregivers and transport staff · Annual fall prevention refresher course for all nonnursing caregivers and transport staff.
Inadequate communication among disciplines	No consistent way for staff to recognize patients at high risk for falls	· Implement yellow fall prevention bracelet for every patient assessed to be at high risk for falls. · “Fall Risk” emblems to be placed on doors and patient activity boards to signify patient at high risk.
Patient not monitored as required by policy/procedure	Fall prevention monitoring not viewed by nursing staff to be a high priority task	· Importance of fall prevention monitoring reinforced by nurse manager at staff meetings · Monthly report of patient fall occurrences shared with staff, along with common factors that precipitated the falls